Health insurance in Arizona
- Arizona residents use HealthCare.gov to enroll in exchange plans
- Open enrollment for 2019 coverage in Arizona ended on December 15, but enrollment is still possible for Arizonans who have qualifying events.
- Short-term health plans are available in Arizona with initial plan terms up to 185 days.
- Five insurers offering plans for 2019, but rural areas still have just BCBSAZ.
- Average premiums are 6.3 percent lower in 2019, but average premium subsidies are significantly smaller in some areas.
- Arizona’s uninsured rate has dropped by 41 percent since 2013, but is still higher than the national average.
- Overall exchange enrollment dropped by more than 15% in 2018, with 166,000 people enrolling.
- Arizona has expanded Medicaid, but is seeking federal approval for a work requirement and lifetime coverage limit.
- Slightly less than 18 percent of Arizona residents are enrolled in Medicare. Of those, 39 percent were enrolled in Medicare Advantage.
- After the 2018 election, Arizona’s congressional delegation tilts slightly in favor of the ACA.
Arizona’s health insurance marketplace
Arizona uses the federally-facilitated exchange, so residents enroll through HealthCare.gov. Open enrollment for 2019 plans ended on December 15, but enrollment is still possible for Arizonans who have qualifying events.
Arizona made headlines in the fall of 2016, due to the number of insurers leaving the exchange and the significant rate increases for 2017. But for 2018, Arizona had among the smallest rate increases in the country, with rates virtually unchanged from 2017.
And for 2019, three insurers have joined the exchange, and average rates are lower than they were in 2018. (But premium subsidies are also lower than they were in 2018, with enrollees in some areas finding that the new insurers are offering lower-priced benchmark plans that are resulting in much smaller subsidies and net premiums that are higher than they were in 2018.)
Average pre-subsidy rate increases in Arizona were 57 percent for 2017. Only Oklahoma had a higher average rate increase. And in Arizona’s federally facilitated health insurance exchange, premiums for benchmark plans (second-lowest-cost silver plan, on which subsidies are based) increased an average of 116 percent, the highest of any state. That means subsidies grew sharply in Arizona for 2017.
Rate increases are calculated before any subsidies are applied; subsidies were much larger in Arizona in 2017, offsetting all or most of the rate increase for enrollees who were subsidy-eligible (69 percent of exchange enrollees were subsidy-eligible in 2016; that grew to 86 percent in 2017). For 2018, the subsidy amounts didn’t need to change significantly, given the minor fluctuation in average premiums.
In 2015, there were 11 carriers offering exchange plans in Arizona. By 2016, there were eight — Meritus, the state’s Consumer Operated and Oriented Plan was among 12 CO-OPs that had folded by early November 2015.
With Aetna’s departure from the Arizona exchange and Cigna’s decision to exit Maricopa County (the only county where they were planning to offer coverage) at the end of 2016, only two carriers offered 2017 coverage to Arizonans through the exchange. Both of them remained in the exchange for 2018.
But for 2019, there are five, with the following average rate changes:
- Blue Cross Blue Shield of Arizona: 0.2 percent average increase
- Health Net of Arizona: 6.3 percent average decrease
- Cigna: 22 percent average decrease (Cigna has rejoined the exchange for 2019, after only offering plans outside the exchange in 2017 and 2018)
- Oscar: new to the market, so no applicable rate change
- Bright Health: new to the market, so no applicable rate change
Average premiums in Arizona’s exchange are 6.3 percent lower for 2019 than they were in 2018. But average benchmark plan rates (on which premium subsidies are based) are 9.6 percent lower. The lower benchmark premiums are concentrated in areas where new insurers entered the market (ie, the Phoenix area) and began offering lower-priced benchmark plans. So enrollees in areas where new plans are available may find that their subsidies are smaller for 2019, and their net premiums are actually higher than they were in 2018. Here’s more about how this works.
In 2018, although there were two insurers offering plans in the exchange, their coverage areas did not overlap. So enrollees could only select from plans offered by a single insurer. But for 2019, enrollees in Maricopa County can select from among four insurers, and enrollees in Pima County have three insurers from which to choose.
Arizona’s population grew by 25 percent between 2000 and 2010, and the influx continues. We’ve put together a summary of Arizona’s overall public health rankings, ACA history, health insurance options, and Medicare and Medicaid enrollment in recent years.
Arizonans enrolled in qualified health plans
Before the exchange opened in the fall of 2013, research by the Kaiser Family Foundation estimated Arizona’s potential market for the health insurance exchange at 551,000 and estimated that 313,000 of those potential consumers would qualify for tax subsidies. Actual results from the 2014 open enrollment period showed that 120,071 people signed up for qualified health plans (QHPs) through Arizona’s health insurance exchange and 144,376 qualified for financial assistance.
During 2016 open enrollment, 203,066 people enrolled in private health plans through Arizona’s exchange. While the initial enrollment was slightly less than it was in 2015, effectuated enrollment as of March 31, 2016, was 8 percent higher than a year prior.
During the 2017 open enrollment period, 196,291 people enrolled in private plans through the Arizona exchange. This was a drop from the year before, but that was the case in most states that use HealthCare.gov. The decline is attributed to uncertainty about the future of the ACA, along with the fact that the Trump Administration scaled back marketing and outreach for HealthCare.gov in the final week of open enrollment.
For 2018 plans, only 165,758 people signed up for coverage during open enrollment. That was more than a 15 percent decline — only West Virginia and Louisiana had enrollment totals that were lower percentages of their 2017 enrollment. 154,435 of those enrollees had effectuated their coverage as of early 2018.
Medicaid in Arizona
Arizona Medicaid is called AHCCCS, for Arizona Health Care Cost Containment System.
Former Gov. Brewer followed a different course than most Republican governors and pushed hard for Medicaid expansion in Arizona. A bill authorizing expansion was passed with some Republican support and signed into law by Brewer in 2013.
However, the expansion has been repeatedly challenged. The Arizona legislature in February 2015 passed SB1092, which requires the state to seek an annual waiver from CMS to allow additional eligibility restrictions for Arizona’s Medicaid program – Arizona Health Care Cost Containment System (AHCCCS, which is pronounced “access”). Gov. Ducey signed the bill into law in March 2015.
In September 2016, the Obama Administration CMS approved Arizona’s waiver proposal, but eliminated the most conservative aspects of it. The new waiver runs through September 2021. It implemented a requirement for modest health savings account contributions from enrollees with income above the poverty level, and enrollment in an optional (rather than mandatory) job search program.
Under the Obama Administration, CMS did not allow Arizona to implement a work requirement, limit AHCCCS coverage for able-bodied adults to five years, or to charge premiums for people with income below the poverty level. The state also cannot lock people out of AHCCCS for six months if they miss a health savings account contribution, or charge fees for missed health care appointments.
However, the Trump Administration is much more open to the sort of proposals that Arizona made in previous years, and a new Arizona Medicaid waiver is pending CMS approval as of late 2018. The new waiver proposal requests a five-year limit on Medicaid coverage for able-bodied enrollees, along with a work requirement.
With Arizona Medicaid expansion in place for now, 58 percent of uninsured nonelderly people in Arizona are eligible for financial assistance to gain medical insurance coverage through either Medicaid or the marketplace. Forty-two percent of those currently uninsured are not eligible due to immigration status.
Arizona saw a 45 percent increase in monthly Medicaid/CHIP enrollment from 2013 to November 2016, the 14th largest change nationwide. But enrollment plateaued by 2016 (as was the case in most states), and net enrollment was up 41 percent as of August 2018 — slightly lower than it had been a year earlier. Nationally, the average increase is 27 percent as of August 2018, down from 30 percent at the end of 2016.
Learn more about Arizona’s Medicaid program at the Arizona Health Care Cost Containment System website.
Read more about Medicaid expansion in Arizona.
Short-term health insurance in Arizona
Arizona has fairly strict regulations for short-term health insurance plans. The state limits the plans to 185 days, and although renewals are allowed, they’re capped at 180 days. So a short-term plan cannot be in effect for more than one year in Arizona.
The Trump Administration has relaxed the federal rules for short-term plans, allowing them to have initial terms of up to 364 days, and total duration, including renewals, of up to three years. But those rules don’t apply in states like Arizona, that have their own, stricter, rules.
Read more about short-term health insurance in Arizona.
How has Obamacare helped Arizona’s uninsured?
Arizona participates in the federally facilitated marketplace (HealthCare.gov) and has expanded its Medicaid program under the ACA.
HHS reported that from 2010 to 2015, the number of Arizona residents with health insurance increased by 410,000 as a result of the ACA.
According to U.S. Census data, 17.1 percent of Arizona residents were uninsured in 2013, and that had dropped to 10.1 percent by 2017 (that was actually a slight uptick from 2016, when just 10 percent of the state’s population was uninsured; nationwide there was a slightl increase in the uninsured rate in 2017, after the Trump Administration took office).
While Arizona’s uninsured rate improved with Obamacare in effect, it remained above the national average (8.7 percent) in 2017 and is still considered high. The state’s efforts to impose a work requirement and five-year lifetime limit could end up rolling back some of the coverage gains, if the Trump Administration approves the state’s latest Medicaid waiver proposal.
Arizona lawmakers and the Affordable Care Act
Following the 2018 election, Arizona’s Senate delegation will include Jon Kyl, a Republican, and Kyrsten Sinema, a Democrat who defeated Rep. Martha McSally in the race to fill outgoing Senator Jeff Flake’s seat. Sinema believes the ACA should remain in place but be fixed where necessary, whereas McSally has worked to repeal the ACA. Sinema and McSally were both in the House in 2017 when Republican lawmakers tried to repeal the ACA with the American Health Care Act. McSally voted in favor of the act, while Sinema voted against it.
But while Sinema supports the ACA, Kyl strongly opposes the law, and would prefer a “free market” approach to health care (a fully free market approach to health care will never work, unless we’re ok with allowing people to simply die if they can’t afford to pay for their care and/or insurance, at whatever cost the insurance company sees fit to charge them; insurers do not cover pre-existing conditions in a free market model). Kyl served in the Senate for 18 years, alongside John McCain, before retiring in 2012. But when McCain passed away in 2018, Gov. Doug Ducey appointed Kyl to fill McCain’s seat. Kyl had initially said he would do so only until the end of 2018, but he may remain in office longer than that (he has said that he has no plans to run for the seat in 2020).
Going into the 2018 election, Arizona had four Democratic US House representatives, and five Republicans. But Anne Kirkpatrick, a Democrat, won the seat vacated by McSally, flipping District 2 from Republican to Democrat. Kirkpatrick previously represented District 1 in the House, before running for Senate against John McCain in 2016. She voted for the ACA in 2009/2010 and considers that her proudest vote during her time in Congress. Kirkpatrick also wants to allow Americans to buy into Medicare or establish some sort of public option for health coverage.
So beginning in 2019, Arizona’s House delegation will have a slight Democratic tilt, with five Democrats and four Republicans. And Andy Biggs, a Republican who won re-election in District 5, was one of 20 Republican Representatives who voted no on the AHCA in 2017.
In the 2010 election, Arizona voters approved a state constitutional amendment barring any state rules or regulations that would force state residents to participate in a healthcare system. Federal law supersedes state law, so the ACA’s individual mandate still applies in Arizona, although the penalty associated with the mandate no longer applies after the end of 2018.
Despite opposing the ACA in general, former Governor Jan Brewer was in favor of state-run health insurance exchange and said it was preferable to a one-size-fits-all model imposed by the federal government. To that end, Brewer established the Office of Health Insurance Exchange, and the state took numerous steps toward setting up a state-run exchange. However, state legislators and a public majority remaining opposed. Brewer ultimately bowed to public sentiment and defaulted to the federally facilitated marketplace.
Doug Ducey, a Republican, took over the governor’s office in January 2015, and won re-election in 2018. During his campaign, he described himself as “100 percent opposed to Obamacare.” Within months of taking office, he signed House Bill 2643 into law, effectively banning the state from creating a state-run exchange. So Arizona, like most states, continues to use HealthCare.gov.
Brewer was one of several Republican Governors who supported Medicaid expansion despite opposing the ACA in general. Ultimately, Arizona did opt to expand Medicaid under the Affordable Care Act, and Medicaid enrollment in Arizona is 41 percent higher than it was in 2013.
Medicare enrollment in the state of Arizona
As of November 2018, nearly 1.3 million Arizonans were enrolled in Medicare coverage. That’s a little less than 18 percent of Arizona’s population. (A little more than 18 percent of the U.S. population is enrolled in Medicare.)
In 2016, Medicare spent about $8,692 per Arizona enrollee for enrollees with Original Medicare – which was 9 percent lower than the national average of $9,533.
Arizona Medicare recipients can choose between Original Medicare or a private Medicare Advantage plan. As of November 2018, 39 percent of Arizona’s Medicare beneficiaries were enrolled in Medicare Advantage plans. Nationally, about 36 percent of Medicare beneficiaries are enrolled in private plans.
Thirty-seven percent of Arizona Medicare beneficiaries are enrolled in stand-alone Medicare Part D plans, which provide prescription drug coverage. (Nearly all Medicare Advantage plans include Part D coverage as well.)
Arizona health insurance resources
Arizona health reform legislation
Here’s what’s happened recently in terms of state-level health care reform legislation in Arizona:
- Gov. Ducey signed HB2643 into law in April 2015. The legislation effectively bans the state from creating a state-run exchange. In 2015, that was an issue due to the uncertainty surrounding the King v. Burwell lawsuit. But in June 2015, the Supreme Court ruled that premium subsidies are legal in every state, regardless of whether the exchange is run by the state or federal government (if the plaintiffs had prevailed, premium subsidies would have disappeared in states like Arizona that rely on the federally-run exchange).
- Also in 2015, SB1092 was signed into law, requiring the state to continue to ask CMS to approve eligibility changes for Medicaid, including a work requirement and a five-year lifetime coverage limit. The Obama Administration rejected most of the major changes that the state wanted to make, but a new waiver proposal, submitted in late 2017, is much more likely to gain approval under the Trump Administration.
Scroll to the bottom of this page for a round-up of other healthcare reform legislation at the state level in Arizona.
Louise Norris is an individual health insurance broker who has been writing about health insurance and health reform since 2006. She has written dozens of opinions and educational pieces about the Affordable Care Act for healthinsurance.org. Her state health exchange updates are regularly cited by media who cover health reform and by other health insurance experts.